Journal of Personality Disorders, 28(4), pp. 463–482, 2014 © 2014 The Guilford Press
DISCRETE SUBGROUPS OF ADOLESCENTS DIAGNOSED WITH BORDERLINE PERSONALITY DISORDER: A LATENT CLASS ANALYSIS OF PERSONALITY FEATURES Vera Ramos, MSc, Guilherme Canta, PsyD, Filipa de Castro, PhD, and Isabel Leal, PhD
Research suggests that borderline personality disorder (BPD) can be diagnosed in adolescents and is marked by considerable heterogeneity. This study aimed to identify personality features characterizing adolescents with BPD and possible meaningful patterns of heterogeneity that could lead to personality subgroups. The authors analyzed data on 60 adolescents, ages 15 to 18 years, who met DSM criteria for a BPD diagnosis. The authors used latent class analysis (LCA) to identify subgroups based on the personality pattern scales from the Millon Adolescent Clinical Inventory (MACI). LCA indicated that the best-fitting solution was a two-class model, identifying two discrete subgroups of BPD adolescents that were described as internalizing and externalizing. The subgroups were then compared on clinical and sociodemographic variables, measures of personality dimensions, DSM BPD criteria, and perception of attachment styles. Adolescents with a BPD diagnosis constitute a heterogeneous group and vary meaningfully on personality features that can have clinical implications for treatment.
The DSM-IV-TR (American Psychiatric Association [APA], 2000) defines 10 categories of personality disorder (PD). Borderline personality disorder (BPD) is seen the most frequently in clinical practice, with a prevalence of
This article was accepted under the editorship of Robert F. Krueger and John Livesley. From Hospital Garcia de Orta, Child and Adolescent Psychiatry Unit, Almada, Portugal (V. R.); Psychology and Health Research Unit, ISPA – Instituto Universitário, Lisboa, Portugal (V. R., I. L.); Lisbon Psychiatric Hospital Center, Lisboa, Portugal (G. C.); and National Institute of Public Health, Centre for Population Health Research, Cuernavaca, Mexico (F. d. C.) We appreciate the contributions made by the Hospital Garcia de Orta (Child and Adolescent Psychiatry Unit) and Hospital Dona Estefânia (Youth Clinic) for supporting this research project. We are indebted to the adolescent participants and their families for sharing information regarding their conditions. This study was supported in part by a PhD grant of the Portuguese Fundação para a Ciência e Tecnologia (FCT) (Grant SFRH/BD/31996/2006). Address correspondence to Vera Ramos, MSc, Psychology and Health Research Unit, ISPA – Instituto Universitário, Av. Elias Garcia – N. 31 – 4 D – 1000-148, Lisboa, Portugal; E-mail: [email protected]
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1%–2% in the general population. BPD affects 10% of all psychiatric outpatients and between 15% and 25% of inpatients, with a predominance of diagnosis in women (Bradley, Conklin, & Westen, 2007; Leichsenring, Leibing, Kruse, New, & Leweke, 2011; Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004). BPD is a heterogeneous disorder characterized by a pervasive pattern of instability in interpersonal relationships, identity, impulsivity, and affect. BPD is associated with cognitive disturbances, severe functional impairment, high rates of co-occurring psychiatric disorders, and elevated risk for suicide and self-injuring conduct (Paris, 2005, 2010; Skodol et al., 2002; Work Group on Borderline Personality Disorder, 2001). During the past decade, research has provided increasing evidence suggesting that BPD can be identified in the adolescent population and so it seems relevant to study this group, considering that the first clinical presentation of the disorder occurs in adolescence at a mean age of 18 years (Chanen, Jovev, & Jackson, 2007; Lieb et al., 2004; Paris, 2005, 2006; Zanarini, Frankenburg, Khera, & Bleichmar, 2001). The DSM-IV-TR (APA, 2000) is cautious about diagnosing BPD in adolescence, but allows it before 18 years old when enduring maladaptive traits have been present in a pervasive and persistent pattern for at least 1 year and are unlikely to be limited to a developmental stage or an episode of an Axis I disorder. Clinicians and researchers have shown some hesitation about diagnosing BPD in adolescence because personality at that age may lack stability and cohesiveness, and some of the pathological traits are similar to normal features of a developmental crisis (Chang, Sharp, & Ha, 2011). There are also concerns that such a diagnosis could result in stigmatization and a lifelong categorization of dysfunction. However, the existing data suggest that despite the substantial developmental changes in adolescence, enduring maladaptive personality characteristics can be assessed and are not reducible to Axis I disorders (Bradley, Conklin, & Westen, 2005, 2007; Durrett & Westen, 2005; Gunderson, 2009; Westen, Shedler, Durrett, Glass, & Martens, 2003). Recent research has also shown the importance of studying developmental precursors and pathways of personality disorders in adolescence and childhood to prevent the risky and harmful behaviors associated with these disorders (Cicchetti & Crick, 2009). PDs appear to be as prevalent in adolescence as in adulthood (Shiner, 2009). Longitudinal and epidemiological research suggests that 10%–15% of adolescents in community samples meet criteria for PDs, with considerable stability of the personality traits over time, but with a less stable categorical diagnosis (Johnson et al., 2000; Lenzenweger, 1999; Winograd, Cohen, & Chen, 2008). Even if the PDs themselves are less stable than expected, the underlying personality traits are still generally stable in both adolescents and adults (Shiner, 2009). It is important to identify specific and differentiating disorder patterns in adolescence, considering not only the phenomenology but also the underlying personality features (Bradley et al., 2005; Durrett & Westen, 2005; Westen & Chang, 2000; Westen et al., 2003). Further research is
ADOLESCENT SUBGROUPS DIAGNOSED WITH BPD465 needed on adolescent PDs and more specifically on BPD, their precursor symptoms, personality traits, and risk factors (Gratz, Latzman, Tull, Reynolds, & Lejuez, 2011; Leichsenring et al., 2011). The considerable heterogeneity observed across adolescent and adult patients who receive the BPD diagnosis expresses the polythetic nature of the disorder (Lenzenweger, Clarkin, Yeomans, Kernberg, & Levy, 2008). A patient can receive the BPD diagnosis in over 150 different ways based on varying combinations of the nine criteria for the disorder, so that two patients may both be diagnosed with BPD while sharing only one symptom in common (Skodol et al., 2002). This fact has relevant clinical implications, considering that different symptomatic expressions of BPD seem to exist and do not reflect random variation among criteria but rather a meaningful and patterned heterogeneity (Bradley et al., 2005, 2007). Although the DSM-IV-TR uses a categorical (present or absent) diagnosis approach to classification with the assumption that PDs represent categorically distinct structures of psychopathology, most of the current research favors a dimensional personality disorder diagnosis (Krueger, Skodol, Livesley, Shrout, & Huang, 2007). Indeed, differences in personality traits within a diagnostic group may be relevant to the understanding and treatment of patients with the disorder, because elements of both personality traits and BPD symptoms are important for clinical predictions of patient functioning and treatment options (Hopwood & Zanarini, 2010). To find better ways of classification, different approaches have been used to clarify the phenomenological heterogeneity found among those diagnosed with BPD, either by reducing the wide variety of BPD symptoms into a smaller number of broad BPD factors (e.g., identity problems and interpersonal difficulties, affect difficulties, self-harm and impulsivity; Zanarini, 2010) or by clustering subjects into meaningful subgroups of BPD according to their psychological features (Bradley et al., 2005). Lenzenweger et al. (2008) suggested a refinement of the BPD phenotype using a clinically informed model, derived from Kernberg’s conceptualization, which makes predictions regarding the clinical phenomenology of BPD. Patients were divided into three distinct groups: Group 1 is nonaggressive/nonparanoid/nonantisocial higher level BPD patients who tend to be characterized by less negative emotion, less childhood physical abuse, and better social/work functioning; Group 2 is paranoid/nonaggressive/ nonantisocial BPD patients who are phenotypically paranoid, yet nonaggressive, as well as less affiliative (diminished social closeness) and who report higher rates of childhood sexual abuse; Group 3 is aggressive/antisocial/nonparanoid BPD patients who are phenotypically antisocial and aggressive as well as less controlled (diminished constraint), more impulsive, more identity diffused, and psychopathic. A highly relevant effort to classify BPD female adolescents was presented in a study by Bradley et al. (2005), who found evidence supporting four BPD subgroups, described as (a) high functioning internalizing, (b) histrionic, (c) depressive internaliz-
466
RAMOS ET AL.
ing, and (d) angry externalizing. These four personality subgroups could also be divided into those with an internalizing style (high functioning internalizing and depressive internalizing) and those with an externalizing style (histrionic and angry externalizing). The studies previously mentioned have tried to understand the heterogeneity within BPD, while others propose models that seek to understand heterogeneity as an expression of an underlying structure that is present across psychopathology. A considerable amount of research by Krueger and colleagues has shown that an Internalizing/Externalizing spectrum model and its association to personality can provide a framework to understand the underlying factors across mental disorders (Krueger & Eaton, 2010; Krueger, McGue, & Iacono, 2001). Miller and colleagues have applied this model to the study of PTSD and hypothesized that the form and expression of that disorder is influenced by individual differences in terms of internalization versus externalization manifestations, leading to different subgroups of PTSD (Forbes, Elhai, Miller, & Creamer, 2010; Miller, Fogler, Wolf, Kaloupek, & Keane, 2008; Miller, Kaloupek, Dillon, & Keane, 2004; Wolf, Miller, Harrington, & Reardon, 2012). Eaton and colleagues have applied the internalizing/externalizing model to the study of BPD, integrating it into the structure of common mental disorders (Eaton et al., 2011). The authors suggest that BPD incorporates features of both the internalizing and the externalizing dimensions, which therefore has important implications for the study of this structural model of psychopathology (Eaton et al., 2011). So, somehow BPD can be understood as being on the border between the internalizing and the externalizing dimensions. In a study of adolescents with several psychiatric conditions, using dimensional measures of personality traits and pathology, Hopwood and Grilo (2010) reported that borderline personality features appear to relate to both internalizing and externalizing dimensions. Adolescence is a crucial time that can result in the emergence of a consolidated identity or in disruptive psychopathological features such as personality disorders. Considering the few available studies exploring the applicability of personality pathology in adolescence, and the relationship between personality features and psychopathology, the present research intends to engage this challenge. Bearing in mind that the DSM-IV-TR diagnosis of BPD could be supplemented by the assessment of underlying personality traits in order to capture clinically relevant differences between these patients, the assessment of psychopathological and personality features can allow a comprehensive understanding of BPD in adolescents and provide information regarding the two main goals. The first is to explore meaningful subgroups of BPD according to the participants’ personality features. The second is to verify the association between these subgroups and clinical and sociodemographic variables, symptoms based on DSM BPD criteria, and dependency and self-criticism dimensions of personality, as well as the perception of attachment styles.
ADOLESCENT SUBGROUPS DIAGNOSED WITH BPD467
METHOD PARTICIPANTS The study investigated 60 adolescents (male = 16, female = 44) ranging in age from 15 to 18 (M = 15.90, SD = 1.05) who met DSM-IV-TR criteria for a clinical diagnosis of BPD. The participants were drawn from a total sample of 116 adolescents who completed the Childhood Interview for DSM-IV (CI-BPD; Zanarini, 2003). Table 1 summarizes the characteristics of the sample. Inclusion criteria were having five or more BPD criteria according to the CI-BPD, manifesting clinically relevant symptoms for more than 2 years, and having at least one available parent or long-term caregiver. ParTABLE 1. Characterization of Adolescent Participants (N = 60) in Relation to Demographic, Clinical, and Treatment Variables Participants Variables Patient Variables Age (M; SD) Gender Girls Boys Level of Education 5th, 6th Grade 7th, 8th, 9th Grade 10th, 11th, 12th Grade Technical Course Family Type Nuclear Single Parent–Mother Single Parent–Father Remarried Family Living with Other Family Members Other Situation Significant Life Events (>1) Self or Family Illness Divorce of Parents Death of Parent/Caregiver Separation from Parent Domestic Violence/Neglect/Physical Abuse Abandonment by One/Both Parent(s) Sexual Abuse Familial Substance Abuse Several Changes of Residence Birth of a Sibling Clinical and Treatment Variables Symptoms (>1) Impulsivity Suicidal Behavior/Self-Mutilating Behavior Affective Instability Inappropriate and Intense Anger Type of Treatment Psychiatry Psychology Both Psychiatric Medication Previous Psychiatric Hospitalizations
N
%
15.90 (1.05) 44 16
73.3 26.7
9 28 18 5
15.0 46.7 30.0 8.3
26 15 2 8 7 2
43.3 25.0 3.3 13.3 11.7 3.4
33 25 18 16 14 12 11 10 8 7
55.0 41.7 30.0 26.7 23.3 20.0 18.3 16.7 13.3 11.7
58 32 59 44
96.7 53.3 98.3 73.3
34 9 17 44 18
56.7 15.0 28.3 73.3 30.0
RAMOS ET AL.
468
FIGURE 1. Flow of participants in the sample.
ticipants were a convenience sample of adolescents referred to the research by mental health clinicians (child and adolescent psychiatrists and clinical psychologists, specialists with more than 10 years of clinical professional experience) from outpatient child and adolescent mental health clinics of three state hospitals (a university hospital, a child and adolescent specialty hospital, and a central hospital) in the greater Lisbon metropolitan area, covering the urban areas of Lisbon and Almada in Portugal. Figure 1 presents the flow of participants according to inclusion criteria, and those included in the final analyses.
PROCEDURES After approval by the Institutional Review Boards and Ethics Committees of the three state hospitals, data collection was initiated. First, several clinicians (child psychiatrists and psychologists with more than 10 years of professional experience) working in the child mental health units were contacted to provide referrals of adolescent patients with a possible BPD diagnosis who met the inclusion criteria. Then all the adolescents were interviewed using a semistructured interview schedule. The diagnostic interview, the CI-BPD (Zanarini, 2003), which assesses DSM-IV BPD in adolescents, was administered individually and privately by two licensed clinicians. These clinicians (the first author and a clinical assistant) are clinical psychologists with master’s degrees in clinical psychology who specialize in child and adolescent psychology and have worked in a child
ADOLESCENT SUBGROUPS DIAGNOSED WITH BPD469 and adolescent mental health setting for more than 8 years. To determine interrater reliability, 11 interviews of our research sample were audio-recorded and the two trained clinicians independently coded the nine criteria for this set of 11 patients (18.33% of the sample). Cohen’s kappa coefficient was computed to assess the reliability of these codings by computing item by item across both clinicians. Interrater reliability across the nine items was excellent as indexed by Cohen’s kappa (κ = .95; z = 10.52, p = .000). The percentage of overall agreement between clinicians was 97.98%, ranging from 83.47% to 100%. Those who met the inclusion criteria were contacted to take part in the study. The adolescents and their parents were interviewed separately in a clinical outpatient setting, with the objective of collecting relevant clinical data and completing the assessment instruments. Informed consent from the participants and their parents was obtained and standards of ethical treatment were followed. The informed consent form explained the aims of the study, emphasizing that participation in the research was voluntary and could be interrupted at any time without any consequences.
MEASURES Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD). The CI-BPD is a semistructured interview that assesses DSM-IV BPD in latency-age children and adolescents (Zanarini, 2003). It consists of nine criteria that reflect symptoms of BPD. After asking a series of corresponding questions, the interviewer rates each criterion with a score of 0 (absent), 1 (probably present), or 2 (definitely present). The patient meets criteria for BPD (receiving an overall score of 2) if five or more criteria are met at the 2-level. Meeting four criteria at the 2-level yields an overall score of 1. If the patient meets three or fewer criteria at the 2-level, then an overall score of 0 is given. The CI-BPD has adequate psychometric characteristics; reliability analyses have yielded good kappa values for the several criteria (kappa = 0.65–0.93) and good internal consistency with a Cronbach’s alpha of 0.81 (Chang et al., 2011). Millon Adolescent Clinical Inventory (MACI). The MACI (Millon, Millon, & Davis, 1993) consists of 160 true-false items of a self-administered inventory that was developed and normed in clinical samples. The MACI has 27 clinical scales that include personality patterns (12 scales), expressed concerns (8 scales), clinical syndromes (7 scales), and 3 modifying indices scales. This widely used clinical assessment instrument (McCann, 1999; Millon et al., 1993) has demonstrated acceptable internal consistency and test-retest reliability, and has been validated against various measures by several different research groups (McCann, 1999; Romm, Bockian, & Harvey, 1999). The Portuguese version of this inventory presents good psychometric characteristics. Cronbach’s alpha values for the different scales varied between 0.64 to 0.89, and good test-retest agreement for the personality patterns (0.64–0.87) and the expressed concerns (0.64–0.89), while concurrent validity was quite good (kappa >0.70) for clinical syn-
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RAMOS ET AL.
dromes and for validity indices (Cavaco, 2004). For analytical purposes, we generated a new categorical variable based on the level of base rate scores using the thresholds derived from the original profiling classification of the instrument (McCann, 1999; Millon et al., 1993):
DISCRETE SUBGROUPS OF ADOLESCENTS DIAGNOSED WITH BORDERLINE PERSONALITY DISORDER: A LATENT CLASS ANALYSIS OF PERSONALITY FEATURES Vera Ramos, MSc, Guilherme Canta, PsyD, Filipa de Castro, PhD, and Isabel Leal, PhD
Research suggests that borderline personality disorder (BPD) can be diagnosed in adolescents and is marked by considerable heterogeneity. This study aimed to identify personality features characterizing adolescents with BPD and possible meaningful patterns of heterogeneity that could lead to personality subgroups. The authors analyzed data on 60 adolescents, ages 15 to 18 years, who met DSM criteria for a BPD diagnosis. The authors used latent class analysis (LCA) to identify subgroups based on the personality pattern scales from the Millon Adolescent Clinical Inventory (MACI). LCA indicated that the best-fitting solution was a two-class model, identifying two discrete subgroups of BPD adolescents that were described as internalizing and externalizing. The subgroups were then compared on clinical and sociodemographic variables, measures of personality dimensions, DSM BPD criteria, and perception of attachment styles. Adolescents with a BPD diagnosis constitute a heterogeneous group and vary meaningfully on personality features that can have clinical implications for treatment.
The DSM-IV-TR (American Psychiatric Association [APA], 2000) defines 10 categories of personality disorder (PD). Borderline personality disorder (BPD) is seen the most frequently in clinical practice, with a prevalence of
This article was accepted under the editorship of Robert F. Krueger and John Livesley. From Hospital Garcia de Orta, Child and Adolescent Psychiatry Unit, Almada, Portugal (V. R.); Psychology and Health Research Unit, ISPA – Instituto Universitário, Lisboa, Portugal (V. R., I. L.); Lisbon Psychiatric Hospital Center, Lisboa, Portugal (G. C.); and National Institute of Public Health, Centre for Population Health Research, Cuernavaca, Mexico (F. d. C.) We appreciate the contributions made by the Hospital Garcia de Orta (Child and Adolescent Psychiatry Unit) and Hospital Dona Estefânia (Youth Clinic) for supporting this research project. We are indebted to the adolescent participants and their families for sharing information regarding their conditions. This study was supported in part by a PhD grant of the Portuguese Fundação para a Ciência e Tecnologia (FCT) (Grant SFRH/BD/31996/2006). Address correspondence to Vera Ramos, MSc, Psychology and Health Research Unit, ISPA – Instituto Universitário, Av. Elias Garcia – N. 31 – 4 D – 1000-148, Lisboa, Portugal; E-mail: [email protected]
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1%–2% in the general population. BPD affects 10% of all psychiatric outpatients and between 15% and 25% of inpatients, with a predominance of diagnosis in women (Bradley, Conklin, & Westen, 2007; Leichsenring, Leibing, Kruse, New, & Leweke, 2011; Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004). BPD is a heterogeneous disorder characterized by a pervasive pattern of instability in interpersonal relationships, identity, impulsivity, and affect. BPD is associated with cognitive disturbances, severe functional impairment, high rates of co-occurring psychiatric disorders, and elevated risk for suicide and self-injuring conduct (Paris, 2005, 2010; Skodol et al., 2002; Work Group on Borderline Personality Disorder, 2001). During the past decade, research has provided increasing evidence suggesting that BPD can be identified in the adolescent population and so it seems relevant to study this group, considering that the first clinical presentation of the disorder occurs in adolescence at a mean age of 18 years (Chanen, Jovev, & Jackson, 2007; Lieb et al., 2004; Paris, 2005, 2006; Zanarini, Frankenburg, Khera, & Bleichmar, 2001). The DSM-IV-TR (APA, 2000) is cautious about diagnosing BPD in adolescence, but allows it before 18 years old when enduring maladaptive traits have been present in a pervasive and persistent pattern for at least 1 year and are unlikely to be limited to a developmental stage or an episode of an Axis I disorder. Clinicians and researchers have shown some hesitation about diagnosing BPD in adolescence because personality at that age may lack stability and cohesiveness, and some of the pathological traits are similar to normal features of a developmental crisis (Chang, Sharp, & Ha, 2011). There are also concerns that such a diagnosis could result in stigmatization and a lifelong categorization of dysfunction. However, the existing data suggest that despite the substantial developmental changes in adolescence, enduring maladaptive personality characteristics can be assessed and are not reducible to Axis I disorders (Bradley, Conklin, & Westen, 2005, 2007; Durrett & Westen, 2005; Gunderson, 2009; Westen, Shedler, Durrett, Glass, & Martens, 2003). Recent research has also shown the importance of studying developmental precursors and pathways of personality disorders in adolescence and childhood to prevent the risky and harmful behaviors associated with these disorders (Cicchetti & Crick, 2009). PDs appear to be as prevalent in adolescence as in adulthood (Shiner, 2009). Longitudinal and epidemiological research suggests that 10%–15% of adolescents in community samples meet criteria for PDs, with considerable stability of the personality traits over time, but with a less stable categorical diagnosis (Johnson et al., 2000; Lenzenweger, 1999; Winograd, Cohen, & Chen, 2008). Even if the PDs themselves are less stable than expected, the underlying personality traits are still generally stable in both adolescents and adults (Shiner, 2009). It is important to identify specific and differentiating disorder patterns in adolescence, considering not only the phenomenology but also the underlying personality features (Bradley et al., 2005; Durrett & Westen, 2005; Westen & Chang, 2000; Westen et al., 2003). Further research is
ADOLESCENT SUBGROUPS DIAGNOSED WITH BPD465 needed on adolescent PDs and more specifically on BPD, their precursor symptoms, personality traits, and risk factors (Gratz, Latzman, Tull, Reynolds, & Lejuez, 2011; Leichsenring et al., 2011). The considerable heterogeneity observed across adolescent and adult patients who receive the BPD diagnosis expresses the polythetic nature of the disorder (Lenzenweger, Clarkin, Yeomans, Kernberg, & Levy, 2008). A patient can receive the BPD diagnosis in over 150 different ways based on varying combinations of the nine criteria for the disorder, so that two patients may both be diagnosed with BPD while sharing only one symptom in common (Skodol et al., 2002). This fact has relevant clinical implications, considering that different symptomatic expressions of BPD seem to exist and do not reflect random variation among criteria but rather a meaningful and patterned heterogeneity (Bradley et al., 2005, 2007). Although the DSM-IV-TR uses a categorical (present or absent) diagnosis approach to classification with the assumption that PDs represent categorically distinct structures of psychopathology, most of the current research favors a dimensional personality disorder diagnosis (Krueger, Skodol, Livesley, Shrout, & Huang, 2007). Indeed, differences in personality traits within a diagnostic group may be relevant to the understanding and treatment of patients with the disorder, because elements of both personality traits and BPD symptoms are important for clinical predictions of patient functioning and treatment options (Hopwood & Zanarini, 2010). To find better ways of classification, different approaches have been used to clarify the phenomenological heterogeneity found among those diagnosed with BPD, either by reducing the wide variety of BPD symptoms into a smaller number of broad BPD factors (e.g., identity problems and interpersonal difficulties, affect difficulties, self-harm and impulsivity; Zanarini, 2010) or by clustering subjects into meaningful subgroups of BPD according to their psychological features (Bradley et al., 2005). Lenzenweger et al. (2008) suggested a refinement of the BPD phenotype using a clinically informed model, derived from Kernberg’s conceptualization, which makes predictions regarding the clinical phenomenology of BPD. Patients were divided into three distinct groups: Group 1 is nonaggressive/nonparanoid/nonantisocial higher level BPD patients who tend to be characterized by less negative emotion, less childhood physical abuse, and better social/work functioning; Group 2 is paranoid/nonaggressive/ nonantisocial BPD patients who are phenotypically paranoid, yet nonaggressive, as well as less affiliative (diminished social closeness) and who report higher rates of childhood sexual abuse; Group 3 is aggressive/antisocial/nonparanoid BPD patients who are phenotypically antisocial and aggressive as well as less controlled (diminished constraint), more impulsive, more identity diffused, and psychopathic. A highly relevant effort to classify BPD female adolescents was presented in a study by Bradley et al. (2005), who found evidence supporting four BPD subgroups, described as (a) high functioning internalizing, (b) histrionic, (c) depressive internaliz-
466
RAMOS ET AL.
ing, and (d) angry externalizing. These four personality subgroups could also be divided into those with an internalizing style (high functioning internalizing and depressive internalizing) and those with an externalizing style (histrionic and angry externalizing). The studies previously mentioned have tried to understand the heterogeneity within BPD, while others propose models that seek to understand heterogeneity as an expression of an underlying structure that is present across psychopathology. A considerable amount of research by Krueger and colleagues has shown that an Internalizing/Externalizing spectrum model and its association to personality can provide a framework to understand the underlying factors across mental disorders (Krueger & Eaton, 2010; Krueger, McGue, & Iacono, 2001). Miller and colleagues have applied this model to the study of PTSD and hypothesized that the form and expression of that disorder is influenced by individual differences in terms of internalization versus externalization manifestations, leading to different subgroups of PTSD (Forbes, Elhai, Miller, & Creamer, 2010; Miller, Fogler, Wolf, Kaloupek, & Keane, 2008; Miller, Kaloupek, Dillon, & Keane, 2004; Wolf, Miller, Harrington, & Reardon, 2012). Eaton and colleagues have applied the internalizing/externalizing model to the study of BPD, integrating it into the structure of common mental disorders (Eaton et al., 2011). The authors suggest that BPD incorporates features of both the internalizing and the externalizing dimensions, which therefore has important implications for the study of this structural model of psychopathology (Eaton et al., 2011). So, somehow BPD can be understood as being on the border between the internalizing and the externalizing dimensions. In a study of adolescents with several psychiatric conditions, using dimensional measures of personality traits and pathology, Hopwood and Grilo (2010) reported that borderline personality features appear to relate to both internalizing and externalizing dimensions. Adolescence is a crucial time that can result in the emergence of a consolidated identity or in disruptive psychopathological features such as personality disorders. Considering the few available studies exploring the applicability of personality pathology in adolescence, and the relationship between personality features and psychopathology, the present research intends to engage this challenge. Bearing in mind that the DSM-IV-TR diagnosis of BPD could be supplemented by the assessment of underlying personality traits in order to capture clinically relevant differences between these patients, the assessment of psychopathological and personality features can allow a comprehensive understanding of BPD in adolescents and provide information regarding the two main goals. The first is to explore meaningful subgroups of BPD according to the participants’ personality features. The second is to verify the association between these subgroups and clinical and sociodemographic variables, symptoms based on DSM BPD criteria, and dependency and self-criticism dimensions of personality, as well as the perception of attachment styles.
ADOLESCENT SUBGROUPS DIAGNOSED WITH BPD467
METHOD PARTICIPANTS The study investigated 60 adolescents (male = 16, female = 44) ranging in age from 15 to 18 (M = 15.90, SD = 1.05) who met DSM-IV-TR criteria for a clinical diagnosis of BPD. The participants were drawn from a total sample of 116 adolescents who completed the Childhood Interview for DSM-IV (CI-BPD; Zanarini, 2003). Table 1 summarizes the characteristics of the sample. Inclusion criteria were having five or more BPD criteria according to the CI-BPD, manifesting clinically relevant symptoms for more than 2 years, and having at least one available parent or long-term caregiver. ParTABLE 1. Characterization of Adolescent Participants (N = 60) in Relation to Demographic, Clinical, and Treatment Variables Participants Variables Patient Variables Age (M; SD) Gender Girls Boys Level of Education 5th, 6th Grade 7th, 8th, 9th Grade 10th, 11th, 12th Grade Technical Course Family Type Nuclear Single Parent–Mother Single Parent–Father Remarried Family Living with Other Family Members Other Situation Significant Life Events (>1) Self or Family Illness Divorce of Parents Death of Parent/Caregiver Separation from Parent Domestic Violence/Neglect/Physical Abuse Abandonment by One/Both Parent(s) Sexual Abuse Familial Substance Abuse Several Changes of Residence Birth of a Sibling Clinical and Treatment Variables Symptoms (>1) Impulsivity Suicidal Behavior/Self-Mutilating Behavior Affective Instability Inappropriate and Intense Anger Type of Treatment Psychiatry Psychology Both Psychiatric Medication Previous Psychiatric Hospitalizations
N
%
15.90 (1.05) 44 16
73.3 26.7
9 28 18 5
15.0 46.7 30.0 8.3
26 15 2 8 7 2
43.3 25.0 3.3 13.3 11.7 3.4
33 25 18 16 14 12 11 10 8 7
55.0 41.7 30.0 26.7 23.3 20.0 18.3 16.7 13.3 11.7
58 32 59 44
96.7 53.3 98.3 73.3
34 9 17 44 18
56.7 15.0 28.3 73.3 30.0
RAMOS ET AL.
468
FIGURE 1. Flow of participants in the sample.
ticipants were a convenience sample of adolescents referred to the research by mental health clinicians (child and adolescent psychiatrists and clinical psychologists, specialists with more than 10 years of clinical professional experience) from outpatient child and adolescent mental health clinics of three state hospitals (a university hospital, a child and adolescent specialty hospital, and a central hospital) in the greater Lisbon metropolitan area, covering the urban areas of Lisbon and Almada in Portugal. Figure 1 presents the flow of participants according to inclusion criteria, and those included in the final analyses.
PROCEDURES After approval by the Institutional Review Boards and Ethics Committees of the three state hospitals, data collection was initiated. First, several clinicians (child psychiatrists and psychologists with more than 10 years of professional experience) working in the child mental health units were contacted to provide referrals of adolescent patients with a possible BPD diagnosis who met the inclusion criteria. Then all the adolescents were interviewed using a semistructured interview schedule. The diagnostic interview, the CI-BPD (Zanarini, 2003), which assesses DSM-IV BPD in adolescents, was administered individually and privately by two licensed clinicians. These clinicians (the first author and a clinical assistant) are clinical psychologists with master’s degrees in clinical psychology who specialize in child and adolescent psychology and have worked in a child
ADOLESCENT SUBGROUPS DIAGNOSED WITH BPD469 and adolescent mental health setting for more than 8 years. To determine interrater reliability, 11 interviews of our research sample were audio-recorded and the two trained clinicians independently coded the nine criteria for this set of 11 patients (18.33% of the sample). Cohen’s kappa coefficient was computed to assess the reliability of these codings by computing item by item across both clinicians. Interrater reliability across the nine items was excellent as indexed by Cohen’s kappa (κ = .95; z = 10.52, p = .000). The percentage of overall agreement between clinicians was 97.98%, ranging from 83.47% to 100%. Those who met the inclusion criteria were contacted to take part in the study. The adolescents and their parents were interviewed separately in a clinical outpatient setting, with the objective of collecting relevant clinical data and completing the assessment instruments. Informed consent from the participants and their parents was obtained and standards of ethical treatment were followed. The informed consent form explained the aims of the study, emphasizing that participation in the research was voluntary and could be interrupted at any time without any consequences.
MEASURES Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD). The CI-BPD is a semistructured interview that assesses DSM-IV BPD in latency-age children and adolescents (Zanarini, 2003). It consists of nine criteria that reflect symptoms of BPD. After asking a series of corresponding questions, the interviewer rates each criterion with a score of 0 (absent), 1 (probably present), or 2 (definitely present). The patient meets criteria for BPD (receiving an overall score of 2) if five or more criteria are met at the 2-level. Meeting four criteria at the 2-level yields an overall score of 1. If the patient meets three or fewer criteria at the 2-level, then an overall score of 0 is given. The CI-BPD has adequate psychometric characteristics; reliability analyses have yielded good kappa values for the several criteria (kappa = 0.65–0.93) and good internal consistency with a Cronbach’s alpha of 0.81 (Chang et al., 2011). Millon Adolescent Clinical Inventory (MACI). The MACI (Millon, Millon, & Davis, 1993) consists of 160 true-false items of a self-administered inventory that was developed and normed in clinical samples. The MACI has 27 clinical scales that include personality patterns (12 scales), expressed concerns (8 scales), clinical syndromes (7 scales), and 3 modifying indices scales. This widely used clinical assessment instrument (McCann, 1999; Millon et al., 1993) has demonstrated acceptable internal consistency and test-retest reliability, and has been validated against various measures by several different research groups (McCann, 1999; Romm, Bockian, & Harvey, 1999). The Portuguese version of this inventory presents good psychometric characteristics. Cronbach’s alpha values for the different scales varied between 0.64 to 0.89, and good test-retest agreement for the personality patterns (0.64–0.87) and the expressed concerns (0.64–0.89), while concurrent validity was quite good (kappa >0.70) for clinical syn-
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dromes and for validity indices (Cavaco, 2004). For analytical purposes, we generated a new categorical variable based on the level of base rate scores using the thresholds derived from the original profiling classification of the instrument (McCann, 1999; Millon et al., 1993):
